CLINICAL PROBLEM SOLVING I
Katie Blow
DPT Class of 2016
11/5/2014
Purpose


Present PT management for a patient
post subarachnoid hemorrhage
Evaluate whether the Berg Balance
Test predicts functional status at
discharge from inpatient rehab
Patient History


60 yr old male admitted s/p fall
vs. trauma 2 days prior to eval


Right frontal hemorrhage,
bilateral temporo-parietal
subarachnoid hemorrhage (SAH)

Other injuries: Maxillary
fracture, R orbital fracture, R
distal radius fracture
Additional Information:


Vtach
Pertinent PMH:


Chest pain reported overnight,
but EKG and two sets of
cardiac enzymes negative
DM, HTN, hyperlipidemia
Precaution:

Non-weight bearing on right
upper extremity
Initial Evaluation




Pain: 8/10 in forearm and head
Mental Status: lethargic 
increasingly alertness
 Alert & Oriented x3
 Single step commands
Motor: 3+/5 bilateral lower
extremities
Mobility:
 Supine  sit minA
 Sit  stand CGA-minA
Alert & Oriented x3
3+/5
1.
2.
3.
4.
Person
Place
Time
Situation
Full ROM against gravity,
slight resistance
MinA= minimal assist
Therapist performs 25% of
transfer
CGA= contact guard
assist
Therapist contact maintained
on pt but no physical support
Initial Evaluation

Gait:




Loss of balance to right, frequent lateral
missteps, anterior lean, postural sway
Complaint of dizziness
Balance:


Impulsive
Short Berg Balance Test 16/28 (<23
considered increased risk for falling)
Assessment

Moderate deficits in balance, gait,
strength, endurance, and cognition
Plan of Care



Treatment Goals:
 Supine  sit with supervision (S)
 Sit  stand with S
 Ambulate 200 ft with S, no loss of balance
 Ascend/descend 6 steps with handrails with S
Plan:
 See patient 5x/week to improve balance, gait, strength,
endurance, and cognition
Discharge: Inpatient rehab
Prognosis

Fair to good
 Young
 Healthy
 Family
support
 Active prior to injury
 Participatory in therapy
Clinical Question

In a 60 year old male with a subarachnoid
hemorrhage, does the Berg Balance Test
predict functional status at discharge from
inpatient rehab?
Evidence #1
Admission Balance and Outcomes of
Patients Admitted for Acute Inpatient
Rehabilitation
Juneja, 1998
Admission Balance and Outcomes of Patients Admitted for Acute
Inpatient Rehabilitation
Juneja, 1998

Objectives
Evaluate relationship between a measure of balance
and a measure of functional independence
 Determine if balance scores collected at rehabilitation
admission were predictive of rehabilitation outcomes,
including length of rehabilitative stay, gain in
functional independence scores, and rehabilitation
efficiency

Admission Balance and Outcomes of Patients Admitted for Acute
Inpatient Rehabilitation
Juneja, 1998


Prospective study
45 subjects




Stroke
Traumatic Brain Injury
Other diagnoses
Physical therapists administered Functional
Independence Measure (FIM) and Berg Balance Scale
(BBS) at admission and discharge from inpatient rehab


FIM gain= (FIM admission – FIM discharge)
FIM efficiency= (FIM gain/LOS)
Admission Balance and Outcomes of Patients Admitted for Acute
Inpatient Rehabilitation
Juneja, 1998

Found non-significant data between three groups;
therefore, collapsed into one
Admission Balance and Outcomes of Patients Admitted for Acute
Inpatient Rehabilitation
Juneja, 1998
Results

Balance was not predictive of gain in functional
ability, but the total BBS at admission accounted for
22% of the variance in the FIM efficiency score


FIM efficiency= (FIM gain/LOS)
Reflects a likely relationship between balance and
LOS
Limitations





Small sample size
Older study
Definition of patient subgroups
Patient subgroups collapsed
Used full Berg Balance Test
Evidence #2
Berg Balance Scale and Outcome
Measures in Acquired Brain Injury
Feld, 2001
Berg Balance Scale and Outcome Measures in Acquired Brain Injury
Feld, 2001

Objective

To examine the relationship of the Berg Balance
Scale (BBS) to the outcome measures such as
Functional Independence Measure (FIM) and length
of stay (LOS)
Berg Balance Scale and Outcome Measures in Acquired Brain Injury
Feld, 2001

40 subjects
24 experienced traumatic brain injury
 16 experienced non-traumatic brain injury


BBS and FIM administered within 72 hours of
admission and before discharge
Low BBS score group (<= 42)
 High BBS score group (>= 43)

Low BBS score group
(<=42)
High BBS score group
(>=43)
Traumatic Brain Injury
15
9
Non-traumatic Brain
Injury
12
4
Berg Balance Scale and Outcome Measures in Acquired Brain Injury
Feld, 2001
Admission BBS v. Discharge FIM
Berg Balance Scale and Outcome Measures in Acquired Brain Injury
Feld, 2001
Admission BBS v. LOS
Berg Balance Scale and Outcome Measures in Acquired Brain Injury
Feld, 2001
Results

Upon multiple regression analysis…



FIM at admission best predictor of FIM at discharge
Admission BBS not found to be independent predictor of
FIM at discharge or LOS
ALTHOUGH, patients with balance deficits upon
admission exhibited poorer functional outcomes and
longer LOS
Limitations





Small sample size
Older study
No comparison in results between traumatic v.
non-traumatic brain injury groups
Definition of groups
Used full Berg Balance Test
Significance for My Patient


Berg Balance score can be used to ENHANCE
prediction of functional outcome status from inpatient
rehab; but the score alone is not predictive
FIM at admission is best predictor of FIM at discharge
References

Juneja et al. "Admission Balance and Outcomes of Patients Admitted
for Acute Inpatient Rehabilitation." American Journal of Physical
Medicine & Rehabilitation 77.5 (1998): 388-93. Williams & Wilkins.

Feld, Jody et al. "Berg Balance Scale and Outcome Measures in
Acquired Brain Injury." Neurorehabilitation and Neural Repair 15.239
(2001). Sage.
Questions?